The boy had been diagnosed with a rare form of kidney disease — the previous year and his condition was being managed by the specialist renal paediatric unit at Our Lady’s Children’s Hospital Crumlin. He was having a type of dialysis at home called peritoneal dialysis on an almost daily basis.

Cork City Coroner’s Court heard his parents Emmanuel and Lette, contacted the renal team at the Dublin hospital on the night of Mar 4, 2012, to say that Victor had difficulty breathing and were advised to bring him to Cork University Hospital (CUH). His parents had been in contact with the unit on Mar 2 because of similar concerns and were advised to attend CUH but his condition later improved.

The Odesholas came to the A&E at CUH at midnight where Victor was seen by a paediatric registrar and was diagnosed with fluid on his lungs.

Paediatric registrar Dr Mmoloki Kenosi told the inquest he contacted the consultant paediatric nephrologist on call in Crumlin, Dr Michael Riordan, who advised him the boy needed urgent dialysis to shift the fluid.

Dr Kenosi told how there was a delay in starting the dialysis as Victor’s father had not brought the dialysis machine to the hospital with him. He said the boy’s father said he would be back within 30 minutes but he did not return until 3.50am on Mar 5. He said the dialysis was further delayed as they had to get fluids from the adult renal unit and that it started at around 4am.

However, the boy’s father Emmanuel Odeshola disputed that fact and said he was back at 2am. He told the inquest he could not remember whether they were told to bring in the machine.

The boy’s condition later deteriorated and he had a cardiac arrest and died despite efforts to revive him.

A postmortem by Dr Margaret Bolster found the boy’s heart was double the normal size and the main cause of difficulties was the heart disease.

Dr Riordan told the inquest he had spoken with the nurses and told them that the boy should attend CUH with his machine and fluids. But he stressed that he did not believe that whatever delay would have made any difference to the outcome in this case.

Dr Riordan said he could have looked at sourcing a dialysis machine internally, but he felt that a 30-minute wait was acceptable and that it was better to go with Victor’s machine.

Clinical director of the National Renal Office, Dr Liam Plant, said the safe protocol was the peritoneal dialysis machines travelled with people.

Coroner Dr Myra Cullinane recorded a cause of death of congestive cardiac failure, due to dilated cardiomyopathy on a background of renal disease. She said she did not find the evidence to record a verdict of death by medical misadventure. She recorded a narrative verdict.